EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78716
114 EW RESIDENTS March 2012 Cataract tips from the teachers In the wake of a shake Sherleen Chen, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Cataract and Comprehensive Ophthalmology Massachusetts Eye and Ear Infirmary Carol L. Karp, M.D. Professor of clinical ophthalmology Bascom Palmer Eye Institute University of Miami Miller School of Medicine Carol L. Karp, M.D. Professor of clinical ophthalmology Bascom Palmer Eye Institute University of Miami Miller School of Medicine Roberto Pineda, M.D. Assistant professor of ophthalmology Harvard Medical School Director of Refractive Surgery Massachusetts Eye and Ear Infirmary I he microsurgical confines of anterior segment surgery require precision, steadiness, and a deft touch. A hand tremor can be a frustrating interference to carrying out the fine maneuvers required for cataract surgery. Most surgeons have at some point dealt with and overcome the nervousness and inexperience that con- tribute to hand tremors. Here, we learn from three experienced cataract teachers about their best advice to help surgeons in train- ing manage a tremor. T Sherleen Chen, M.D., and Roberto Pineda, M.D. think of a tremor as something that has both emotional and physical components. In man- aging this issue, the key is preparation for the emotional and physical aspects of the upcom- ing case. Surgery can be stressful. Feeling insecure about the procedure can in- duce anxiety and bring out a tremor. For me, the best way to manage anx- iety about a case is preparation. Be sure that the things you need for the case are available—the patient chart, the intraocular lens calculation, etc. A last-minute frenzy looking for these items can cause stress. I highly recommend watching videos of the procedure well in advance of the surgery. Watch them several times. This is what I do before any new procedure, and if possible, watch someone else do a case. I also write down every surgical step and then put this into my phone. I can quickly look over the list and any pearls at a glance. Seeing the proce- dure several times can significantly relieve anxiety. The other component of a tremor is the physical component. I think about this in trying to control the micro- and macro-environment. By macro-environment, I mean your body and what you do before you get to the operating room. Always have a good breakfast, be well rested, and avoid caffeine and excessive exercise. These factors will allow you to be at your best. Shahzad I. Mian, M.D. Associate professor of ophthalmology and visual sciences University of Michigan Kellogg Eye Center, Ann Arbor Preparation for the micro-envi- ronment is also critical. This means that you must take the time to be sure that your hands and body are comfortable to avoid a tremor. Be sure that the ergonomics of your chair, microscope, foot pedal, and back position will keep you comfort- able. Pay special attention to the wrist rest to support your hands. This is very helpful. I often will have my pinky touching the patient's head to support my hand. These steps will avoid the onset of a tremor. In some cases, these steps are not enough to quiet a tremor. Some surgeons use propranolol 40 mg prior to a case to control their anxi- ety and tremor. I have not tried this. If you do, be sure to test the propra- nolol on a different day, to ensure that you do not have any adverse re- action. In summary, the key in manag- ing a tremor is preparation. This means emotionally, to be ready for the case by reviewing all steps and data, and making sure that physi- cally you are most comfortable. Shahzad I. Mian, M.D. Associate professor of ophthalmology and visual sciences Terry J. Bergstrom Collegiate Professor for Resident Education in Ophthalmology and Visual Sciences University of Michigan Kellogg Eye Center Ann Arbor Having a tremor during micro- surgery is not uncommon for begin- ning surgeons and can have a major impact on surgical technique and outcomes. The vast majority of resi- Eydie G. Miller, M.D. Professor of clinical ophthalmology Director of Glaucoma Service Scheie Eye Institute, University of Pennsylvania Health System, Philadelphia dents entering ophthalmology train- ing programs have little or no expe- rience in performing microsurgery but graduate from medical school with high scholastic credentials and a strong drive to succeed. Intraoper- ative tremors are a function of lack of experience, anxiety associated with surgical performance, and a busy schedule during training. Having a tremor under the mi- croscope is most commonly a func- tion of limited experience using instruments under high magnifica- tion in small spaces. For most resi- dents, this type of tremor improves with practice and experience. Spend- ing time in the wet lab to become fa- miliar with use of the microscope, surgical instruments, and high mag- nification intraocular movements repetitively, especially with supervi- sion from more experienced sur- geons, can have a significant impact. Specific tasks in the wet lab include focus on knowledge of basic surgical instruments, tissue manipulation, and suturing. Skill development with these tasks leads to practice with more advanced steps such as capsulorhexis and phacoemulsifica- tion. More recent advancements in surgical simulators, including the Eyesi (VRmagic, Mannheim, Germany), provide specific modules for anti-tremor training. This may perhaps provide the best quantita- tive feedback regarding skills needed to eliminate intraoperative tremors. Additional studies are needed to show benefits of anti-tremor train- ing with simulators in the operating room. Novice surgeons also have much anxiety over skills necessary to per-